Meniscus rehabilitation for ACU-1 orthosport.pdf

Physiotherapy

1. Meniscal
injuries
Dr. Rafik Radwan
Founder & CEO of fizikcenters
Lecturer Biomechanics, Cairo university

2. Epidemiology
Among most common injuries seen in
orthopedic practice
61 cases per 100,000 per year
Arthroscopic partial menisectomy one
of the most common orthopedic
procedures

3. Assessment

4. History
•Twisting injury with change in direction in younger
patients
•Squatting or falling in older patients
•Acute tear usually has insidious swelling
•Joint line location
•Mechanical complaints

5. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
•Small effusion

6. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests

7. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
•ROM generally normal
•Bucket handle block
•Tight due to effusion

8. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
Non-Weight
bearing tests
Weight bearing
tests

9. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
Non-Weight
bearing tests
Weight bearing
tests

10. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
Non-Weight
bearing tests
Weight bearing
tests

11. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
Non-Weight
bearing tests
Weight bearing
tests

12. Physical
Exam
•Effusion
•Tenderness
•ROM
•Special tests
Non-Weight
bearing tests
Weight bearing
tests

13. Meniscus tear clinical assessment

14. Imaging
•Plain films to assess for
bony injury and OA
•MRI is the gold standard
of diagnosis

15. Treatment

16. Treatment
•Non-surgical treatment
•Surgical treatment

17. Treatment
•Non-surgical treatment
•Surgical treatment
•Non-surgical treatment
Non-surgical treatment is usually reserved for
the elderly type patient and for those with
extensive arthritis, or those who are poor
surgical candidates.
•In the athletic population, non-surgical
treatment is not the recommended option as
the native anatomy of the knee joint and thus
function is not restored, leading to joint
space narrowing and arthritic changes

18. Treatment
•Non-surgical treatment
•Surgical treatment
•Stable, longitudinal <10mm with <3-5mm
displacement
•Degenerative tears with concomitant OA
•<3mm radial tears
•Stable partial tears

19. Patho-
physiologic
Treatment
-pulsed Short wave
MBST
LASER therapy
Interferential current

20. Treatment
•Non-surgical treatment
•Surgical treatment
MeniscectomySurgical RepairTransplantation

21. Treatment
•Non-surgical treatment
•Surgical treatment
•partial or complete meniscectomy is not recommended
as it only provides short term relief of symptoms and the
long-term outcomes are not known.
•a few studies that have compared meniscectomy versus
repair:
❑In a recent study, it was reported that 35% of patients who
received meniscectomy required revision surgery using total knee
arthroplasty, however in those who received meniscal repair
none required revision surgery . Further, they found that
meniscectomy was associated with a 5-year survival rate of only
75% among patients; whereas, meniscal repair was associated
with a 100% 5-year survival rate.
❑Lee et al concluded that for the treatment of medial meniscus
root tears, the arthroscopic pull-out repair provides better clinical
and radiographic outcomes in the long-term than partial
meniscectomy . It also has a higher potential to completely heal
the meniscus that facilitates the ability of the meniscus to
convert axial load into hoop stress
MeniscectomySurgical RepairTransplantation

22. Treatment
•Non-surgical treatment
•Surgical treatment
•Meniscectomy is reserved for the following
types of patients:
❑Patients with chronic root tears and
symptomatic grade-3 or 4 chondral lesions
(iepre-existing arthritis) who fail
nonoperative treatment.
❑Patients with partial root tears, and a
substantial portion of the footprint still
intact
MeniscectomySurgical RepairTransplantation

23. Treatment
•Non-surgical treatment
•Surgical treatment
•Indications
•Radial
•Flap
•Horizontal
•Complex
•White-white tears
MeniscectomySurgical RepairTransplantation

24. Treatment
•Non-surgical treatment
•Surgical treatment
•Goal is to debride tear
and leave stable rim
•Preservation is ideal
•80% satisfactory
function at 5 yrs
•Lateral debridement =
faster degeneration
MeniscectomySurgical RepairTransplantation

25. Treatment
•Non-surgical treatment
•Surgical treatment
•Due to the dissatisfaction with partial meniscectomy in
the treatment of meniscal root tears in the athlete,
there has been a growing interest in meniscal repair ,
and this has led to a number of different types of
repairs with different fixation methods. In the athletic
population, repair of meniscal root injuries is indicated
for both symptomatic relief and prevention of
degenerative joint disease.
•The main indications for meniscal repair include
•1. Acute, traumatic root tears in patients who have yet
to develop osteoarthritis, with the goal of preventing
arthritic changes
2. Chronic symptomatic root tears in young or middle-
aged athletes without significant pre-existing arthritis
MeniscectomySurgical RepairTransplantation

26. Treatment
•Non-surgical treatment
•Surgical treatment
•Relative
Contraindications
•Advanced OA
•Complex tears
•Poor tissue quality
•ACL deficiency
MeniscectomySurgical RepairTransplantation

27. Treatment
•Non-surgical treatment
•Surgical treatment
•Rarely used
•Numerous studies have proven
reduced surgical morbidity with
arthroscopic repair
•Reserved for peripheral tears in
the posterior horn
MeniscectomySurgical RepairTransplantation

28. Treatment
•Non-surgical treatment
•Surgical treatment
•Indications:
•Recurrent pain after partial or total
debridement
•symptomatic with ADLs
•<50yo
•Contraindications:
•Malalignment
•Laxity
•Inflammatory arthritis
•Advanced OA
MeniscectomySurgical RepairTransplantation

29. Treatment
•Non-surgical treatment
•Surgical treatment
•Widely varying reports of success
(Country differences)
•Subjective improvement in
tibiofemoral pain
•No clear long-term benefit in
preventing OA has been established
•Grafts seem to do better when
placed with a bone block
•Preserving some peripheral rim helps
to avoid extrusion
•Variety of meniscal scaffold options
being investigated in animals
MeniscectomySurgical RepairTransplantation

30. Complications

31. Baker cyst
•It is now known that a Baker’s cyst is a bursitis, which is commonly
associated with intra-articular knee pathology such as meniscal
tears, chondral lesions and early osteoarthritis.
•For the clinician dealing with athletes therefore, Baker’s cysts may
be the first indicator that an athlete has an intraarticular joint
pathology
•Through dissection studies, he discovered that this cystic mass
was a distention of the bursa between the semimembranosus and
the medial head of the gastrocnemius.
•However, the name Baker’s cyst was given to honor British surgeon
William Morant Baker, who wrote a description of 8 cases of
popliteal cysts that he had seen in 1877

32. Pathogenesis
and
incidence
Meniscus tears
Large effusions
Osteoarthritis
Chondral lesions
Inflammatory arthritis
Anterior cruciate ligament tears

33. Rehabilitation

34. Post-operative Meniscectomy

35. Phases of
rehab
❑Maximal protection
phase
❑Moderate protection
phase
❑Minimal protection
phase
Post-
Meniscectomy
Post-Meniscal
Repair
➢2 weeks ➢6 weeks
➢2 weeks ➢3 weeks
➢2 weeks ➢3 weeks

36. Phases of
rehab
❑Maximal protection
phase
❑Moderate protection
phase
❑Minimal protection
phase
Post-
Meniscectomy
Post-Meniscal
Repair
➢2 weeks ➢6 weeks
➢2 weeks ➢3 weeks
➢2 weeks ➢3 weeks

37. The maximum protection phase:
The concept is restoring the ROM , minimize
the effusion , improve the proprioception
and mechanoreceptors of the knee
In other words the success of the
rehabilitation is depends on :
-How to adapt the knee with the new
dimensions of the meniscus
-How to help the injured meniscus to
distribute the load
Load adapt
Rehabilitation of meniscectomy

38. The steps of rehabilitation
❑Release the connective tissue around the knee to open the
intra-articular space
❑Increase the power of main stabilizers ( Quadriceps ) and
rotational control ( Hamstrings & gastrocnemius )
❑Proprioception ( movement & position )
❑Start the adaptation from
-Non weight bearing closed chain
-Non weight bearing open chain
-partial weight bearing ( sitting , balanced , proprioception
training )

39. we can change the severity of exercise as
Change the surface from
hard to soft to unstable
Use extra thera-band or
whole body vibration or
balance board
Add cognitive training
for the upper limb or
pelvis
Biofeedback training

40. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

41. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

42. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM exercises
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

43. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

44. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

45. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

46. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

47. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

48. Maximal protection
phase
•Control pain and effusion
•Muscle activation
•ROM
•Release
•Stretching exercise
•Strengthening exercises
•Proprioception
•Partial WB
•Balance exercises

49. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

50. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

51. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

52. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

53. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

54. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

55. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

56. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

57. Moderate protection
phase
•Bilateral WB
•Bilateral balance (standing)
•Proprioception (standing)
•Lunges exercises
•Step up/down
•Squat up to 45
•Leg press up to 90
•Correction of squat mechanics
•Core exercises

58. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

59. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

60. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

61. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

62. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

63. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

64. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

65. Minimal protection
phase
•Unilateral WB
•Unilateral balance
•Landing
•Jumping
•Man running
•Outdoor exercises
•Pivot lunges

66. Knee Program
Exercises

67. Knee Program
Exercises

68. Criteria of return to sport